Monday, October 19, 2009

Took a while, but I finally got back around to enjoying NYC -- or just enjoying everything in general. I just finished a month on the Acute Care Surgery service at Columbia Presbyterian Hospital. I learnt a lot, I worked hard, did 30-hour call (horrible) and actually had a good time. The Surgery residents at Columbia are a fantastic group of people and I had the tremendous help of someone who has helped generations of NYP EM residents survive surgery -- Voula, the acute care surgery service PA. If most PAs are worth their weight in Gold, Voula is worth her weight in Platinum. phew!

First, there were the 3rd row seats in the endzone at the Eagles game in Philly...I was going to go SCUBA diving during this time off, but that all fell through, mostly due to the fault of annoying bosses and failure of appropriate planning. Oh well. That's why I live in NYC and can salvage! Then there was taking Deka to the dog park (she was spade and forbidden to run for a month). She was so excited, she ran laps for the first 15 minutes. Deka is now 9 months old!!!Thursday found me at Carnegie hall with Elena to hear Hayden's "The Seasons" -- a piece I was completely unfamiliar with. Turns out that Hayden drew significant inspiration from Handel's Messiah for this work and it was really beautiful! Full orchestra, full choir, soprano, tenor and bass soloists. Each "season" was unique. Spring was calm and pretty, Summer was a little weird because it had a sad feeling to it, however Fall was fantastic with the "hunt" and the french horns going bells up and balls out crazy and Winter was full of BIG choral stuff with a necessarily rousing finish.

All of this was followed by a weekend in DC w/ my college roommate, Genevieve and her husband, Bren which included a stop by the National Opera Company's Trunk Sale where they were selling old costumes -- both G and I walked away with kickass halloween costumes from Madame Butterfly (Bren stayed home).

Now I'm in Chi-town visiting Aileen and Ashley. Irony of ironies, it's actually warmer here than in NYC (as in, 53 instead of 48, but I'll take it). From here I go to Seattle to see Dave and Katie for the first time in almost a year and a half!

Wait... interactive?? So I click the link and guess what? This is FABULOUS! There is a reason why the NEJM is considered the preeminent medical journal and innovations like this are it. This is a case, presented in pieces (the usual horrible puns apply) with frequent breaks where you "order" lab tests and "create" a differential diagnosis then reassess and "order" more tests/treatments. There are charts, tables, MOVIES, images. Even better, this isn't the "one correct answer" format. It's the "which 5 of these 15 potential diagnoses could this patient have?" There also isn't any sort of giant ERROR buzzer, either. You choose your answers, the green checks and red "x"-es appear and you read an explanation of the answer.

Did I mention the excellent explanations? Sometimes a little too helpful before you click on your answers, but that's what learning is about, right?

NEJM is famous for its long-established "Case Records of the Massacchuttes General Hospital" in which docs get to read a round-table discussion of a complicated case with a number of experts weighing in. Very valuable -- med students everywhere are told to read it -- but its dry and complicated as hell to follow. They literally transcribe the round-table discussion verbatim. I feel that this new interactive case format accomplishes the same goal but I actually learn becuase I'm participating and actually care (I admit it... I don't like to get questions wrong).

Overall, two thumbs up.

While I'm at it, I'm going to put in a one-line plug for the NEJM "Image Challenge" on the website. This shows pictures of pathology -- anything from photographs, radiology, microscopy, gel electrophoresis...etc. You pick the answer from the multiple choice on the side and get told right/wrong. Quick, visual recognition, great for keeping your brain plugged in on overnight where you have to stay awake but don't have the energy for more than a mouse-click.

Sunday, October 18, 2009

There is an article in this weekend’s NY Times that I found very interesting. It’s about the healthcare system in Hawaii – and how GOOD it is! The authors cite that Hawaiians live longer than any other state in the union and they they are generally healthier. The doubters among us say “no shit, Sherlock. It’s BEAUTIFUL all the time!!” However, there were some more intriguing tidbits in the article that made me wonder. Hawaii has the highest rate of breast cancer in the US, however, they have the fewest DEATHS from the disease of any state. Hawaii has the highest percentage of insured in the US and the lowest Medicare costs (possibly again contributable to that whole tropical paradise thing).

But really, the least number of uninsured? Massachuttess has the next lowest number of uninsured at 20%. Hawaii’s uninsured # is 10%. What’s going on? There is a law in Hawaii that every employee who works a minimum of 20 hours per week must have health insurance. Sure, there are people who try to circumvent the systems, employers making sure their employees only work 17 hours per week so that they don’t have to pay insurance, but generally the plans are cheap, no deductible, widely accepted and easily suffice for your average fairly healthy tropical paradise inhabitant.

I was puttering along this article until I hit the section where they start talking about the ERs in Hawaii. The author interviewed an ER doc who spends part of his year in LA and part in Hawaii. He described the Hawaii ER experience as “greased lightning.” Nationally, there are 400 ER visists/1,000 people annually. In Hawaii, that number is 200/1,000 people – half the national average. Again, you could make the tropical paradise argument, but Hawaii is not without its dangers. Anywhere there are highways, there are high-speed car wrecks. Just because the live in paradise doesn’t mean that Hawaiians don’t suffer from heart disease, asthma (highest rate in the US), COPD. Not to mention the kind of trouble the “touristas” can get themselves into with the vast number of adventurous activities available in Hawaii – there’s surfing, jellyfish, climbing, diving, parasailing, base jumping, heat stroke… all recipes for tourists ending up in the ER.

So why is this mystery ER doc saying that Hawaii’s ERs are “greased lightning”? The theory proposed by the article is that there is much better access to family care practitioners and general primary care docs, so patients go to their doctors for all the minor stuff rather than to the ER. i.e.—appropriate use of the primary care physician and the ER. This is something that I am continuously advocating as the root of our healthcare crisis—lack of access to primary care. I also always say that this is not going to be fixed without a massive expansion of our clinic system. The system as it is right now is at its breaking point on all fronts. This is the point at which Rob jumped into to play devil’s advocate.

What is the ratio of primary care physicians to population in Honolulu vs. NYC or Philadelphia? Barring that, what is the population difference? What kinds of numbers is each hospital on Hawaii serving in beds per population vs a NYC hospital? How many insured use the ER vs. primary care for minor complaints? How sick ARE these people in Hawaii (tropical paradise argument again)?

I’ll have to do more research and get back to those valid questions. For now, it appears that the spin on the NYTimes article agrees with my personal opinions – we need more primary care!

Hawaii’s system is not without problems. A number of the hospitals, especially on the outer islands, are failing. The rate of uninsured is increasing due to the current economy and the system is not built to handle the uninsured right now – it is a system built to handle almost 100% insured. It is interesting to wonder if the resources and the finances will be able to withstand what is to come. Also this whole “greased lightning” thing… I can’t see it.Maybe an entirely decompressed healthcare system works. I just don’t know.